A medical mind is precious and fragile: hard to create, easy to corrupt. Doctors invest over 10,000 hours learning how to diagnose and treat. The medical mind exists to help patients and should serve no other purpose. But it is easily corrupted, distracted from its main purpose.
If patient care matters, we must protect the medical mind from service to popular, non-medical ends.
Hard to Create
Medical students submit to a 4-year shaping program: an immersion in a peculiar thought process. Residency continues the formation for another 2, 4, or even 12 years.
The medical mind continues to develop, in practice. Ultimately, patient care adds the fine and necessary texture.
Forming a medical mind is more than taking courses and learning techniques. You cannot become a doctor by memorizing Google Scholar or watching a video.
A mind is more than information. It is an information processing tool, created at great cost.
How Medical Minds Work
With one hand, doctors reach backwards and hang onto medical knowledge. With the other, they grope forwards for new ideas and solutions.
Medical knowledge is not monolithic; it always changes. But neither it is a clean wipe of the medical hard drive to start fresh with a blank mind every Monday.
Given this two-handed approach of past-plus-progress, a medical mind must remain open.
The fact of new information makes some of what we think we know wrong, by definition. The history of medicine is full of attempts to treat using tools which caused obvious harm in hindsight.
Thus, a medical mind must adopt the scientist’s “pride in his/her humility.” Doctors must promote the limits of our knowledge because what we think we know might not be so tomorrow.
Easy to Colonize and Corrupt
The medical mind could remain protected, hidden inside the institution of medicine. But the town comes in, as it should. Doctors serve real people, who live outside.
A resident sits in his room at Idola Saint-Jean long-term care home in Laval, Que., Friday, February 25, 2022. Graham Hughes/The Canadian Press.
I wrote this for The HUB — loads of other great content there too.
Government, the medical profession, and public-sector unions are preventing improvements in our health care.
The Honorable Monique Begin (et al.) wrote in 2009, “When it comes to moving health care practices forward efficiently, Canada is a country of perpetual pilot projects.” Governments need “financial control” and remain “leery” of committing to programs. Pilot programs are easy to shut down “to avoid criticism” or if “budget priorities shift.”1
At first glance, we might blame voters. Canadians rank health care as a top priority in most elections over the last several decades. Voters like Medicare; politicians are loath to change it. The last federal election stood out for (almost) hinging on a debate about health policy. As Sean Speer put it in August, “We are having a Section 92 election in a Section 91 moment.”2 Most of the time, politicians from all parties work hard to avoid saying anything meaningful about health care—especially during an election—aside from pledging support for more of the same.
But we cannot blame health care stasis on politicians or the voters they need to woo. Medicare cannot change because it is locked in an iron triangle consisting of government, the medical profession, and public-sector unions.
Veto Power
The health care triangle is stronger than any party inside it; each party holds de facto veto power over major decisions. Each party seeks to improve its standing and power within the triangle relative to the other parties. When a government attempts change from inside the triangle, it can manage only minor tweaks or redesign. For example, regionalizing services, then centralizing them, then regionalizing again.
Veto guarantees that modern Medicare shares more similarities to its 1960s design than any evidence of meaningful innovation since then.
De facto veto power often gets constitutionalized into law. Consider two examples. In 2012, the Ontario Medical Association won a major battle with the government over labour dispute resolution and representation rights. The government agreed to abide by a binding resolution process with doctors. The government also granted the OMA exclusive “representation rights” agreeing to negotiate with the OMA and no one else. Or consider also that in 1991, the government gave the OMA power to collect dues from all Ontario doctors, whether or not doctors were members or even supportive of OMA policy. Ostensibly, The Ontario Medical Association Dues Act, 1991 empowered the OMA to fund its negotiations with the government, but the bulk of every OMA budget has funded issues unrelated to negotiations for decades.
This is not to pick on physicians; nor is it an attempt to reopen the debate about “rep rights”, arbitration, or dues. We could multiply examples of constitutionalized privilege for the regulatory colleges, universities, public-sector unions, and government itself.
The issue is constitutionalized privilege—the iron triangle between government, the medical profession, and public-sector unions. (Note: the medical profession includes medical associations, licencing bodies, and training programs, not individual doctors.)
Iron Lady Breaks Iron Triangle
In the early 1980s, Prime Minister Margaret Thatcher tackled a similar rigid coalition. John Gray, a political philosopher, described it as “the triangular relationship between government, business and the trade unions.”
Thatcher set to work smashing the relationship. However, she left the welfare state “comparatively intact… the political thrust of early Thatcherism was in the direction of the dismantlement of the corporatist policies of the 1960s and early 1970s.”3
Canada needs something similar: break the health care iron triangle while leaving the welfare state comparatively intact. The (once) friendly relationship between government, doctors, and unions has ossified and become hard, brittle, and inflexible: unable to manage stress or major change.
Institutions, like young trees, become weak and spindly shielded from the pressure and strain of social competition. Secure in the functional monopoly afforded by corporatist-style policy, institutions come to see themselves as existing to mitigate frictions between the other parties within the triangle instead of shaping the individuals inside the institutions themselves. As Yuval Levin, an American author, often says, “Institutions become performative instead of formative.”4
We have no shortage of ideas to improve health care quality and efficiency, such as funding reform, integration of health services, public-private partnerships, and so on. But these ideas do not even reach the level of tactics to implement change. They are the outcome we hope to see after change has been allowed to occur. We do not lack ideas; we lack strategic vision.
The pandemic exposed the lack of resilience in our health system and the desperate need for substantial growth. All parties in the iron triangle agree the system needs change. But the parties cannot agree to any solution which does not benefit their own weight and influence inside the arrangement.
Health care’s iron triangle rests on the concentration of power—a tripartite monopoly. The best way to undermine a monopoly is to invite new parties into the relationship. Break concentrations of power into multiple smaller units. It can be done: Thatcher found a way to do it in Britain. It starts by addressing the iron triangle as the root of resistance to change. If we do not, Canada will remain forever a “country of perpetual pilot projects.”
Before medical politics died in Ontario, a PPSA vote meant three hundred doctors from across the province packed into the basement of a hotel in downtown Toronto.
A room full of frowning doctors debating fees was much like kids lighting matches near a haystack.
Inevitably, someone would yell at the board, insult a colleague, or slander the government. Every so often, the Chair would wack away with his gavel, completely ignored by the angry mob.
At one meeting, a red-faced little man stomped several hundred feet across the front of the room and shoved his face in front of another doctor. The angry man had taken offence. He demanded an immediate apology. Or would the other member care to step outside the chamber?
PPSA VotE Needs More Data
The PPSA appears to offer a 1 per cent increase per year with (hopefully) 2.8 per cent in year three.
But what does this mean?
How do specific fee cuts impact income?
Do we have to work 10 per cent harder for a 1 per cent increase?
How does inflation impact the outcome?
How is income impacted by elimination of thresholds and system redesign?
The OMA used to publish fancy graphs of how physician income has changed relative to inflation. The graphs ended when they became too embarrassing.
Governments changed, but OMA performance stayed the same. Endless sub-inflationary increases imposed by successive governments made the OMA look bad.
In 2015, we pushed the OMA to publish an analysis of net income. It showed a steep decline from 2011 to 2015, with an expected 28 per cent cut by 2017-18:
Hazard a Guess At the Cuts Now?
Let’s hope the OMA offers an update. In the meantime, we can try to do our own.
Consider a physician who bills $160,000 and pays $60,000 in overhead (37.5 %). The total billing will increase at 1 per cent for 2021 and 2022, and 2.8 per cent for 2023.
Let’s assume a general inflation rate of 5 per cent. This means office overhead will grow at 5 per cent each year, and spending power (net income) will decrease by 5 per cent each year.
Medical overhead always outpaces inflation, and general inflation may be closer to 7 per cent, but let’s be conservative.
This gives us an 18.7 per cent net decrease over three years. You will feel like you have 20 per cent less to live on. If inflation runs over 5 per cent, a much higher cut seems reasonable.
Add in all the other specific cuts as they apply to your own specialty.
A Fair Process?
Failure to ratify used to mean rolling the dice at arbitration, but at least you got a second chance.
But the chair of the board of arbitration has warned doctors. Do not expect fee increases; arbitration is already fixed.
This makes arbitration a sham.
The whole point of arbitration was to avoid predetermined outcomes. Remove the power imbalance. Enforce fair bargaining. Do not let one side (government) predetermine the price before negotiation even begins.
But Premier Ford made his final offer in Nov 2019. Between May 1, 2020, and April 30, 2023, Ford will pay 1% and not a penny more (Bill 124).
Some think this fair, but does it even make sense?
In 2020, gas was $1.04 per litre. Today, it is $1.70, in S. Ontario. Government wants to fill the medical gas tank at $1.04, plus 1 per cent per year.
Health Reform on the Fly
The proposed contract has far too many silly details to unpack them all: arbitrary limits to practice size, micro-managing office locations, and more. Each detail requires several paragraphs to unpack.
Consider one example.
In the late 1990s, family doctors were a dying breed. Medical students avoided family medicine, and nearly 1.5 million Ontarians could not find a family doc.
Government absolutely refused to increase fees for GP services. Fee for service (FFS) medicine rewards doctors for meeting as many patient needs as possible. It offers no easy way to contain spending.
In the early 2000s, government agreed to increase payments to primary care, but only if government could gain control of costs.
Primary care reform offered the answer.
A basket of patient-enrolment models (FHNs, FHGs, and FHOs) incentivized doctors to roster patients in return for an annual fee. The top rates for an average patient run around $200 per year, to provide a basket of approximately 130 services.
Very few family docs practice FFS medicine any more, although most specialists still do. FFS is bad, according to the experts. It rewards doctors for providing more services. More services mean the government must spend more on care.
Rostered, patient-enrolment models encourage doctors to offer fewer, longer visits, instead of churning patients for multiple return visits. Rostering incentivizes team care and coming up with creative ways to interact and share information without dragging patients back to clinic.
Whereas FFS incentivizes increased visits, rostering is designed to decrease them.
Government has decided it does not like fewer visits after all.
The Ministry of Health wants FFS visit numbers with rostered-payment certainty. Government aspires to 88 visits per week for every 1300 patients rostered. This will incentivize more frequent, shorter visits. It is hard to see how chopping one long visit into three in order to meet government targets will improve quality or care.
How Should You Vote?
It’s not a great offer. But at least it’s only 3 years.
This comes from the OMA negotiations team, in a town hall meeting. It is almost verbatim.
Better accept this offer or else. There is no guarantee of getting half as good at arbitration.
A Hobson’s choice is one which does not offer an alternative: take it or leave it. Unpalatability of the alternative removes real choice.
Closing Thought – Incomes as Information
“Doctors earn enough.”
“You can take the cut.”
I have heard many variations of this modern noblesse oblige. The average doctor lives well enough.
As a physician, you care about your income. It matters to you and your family. But that is not why your income matters to the rest of the world.
Physician income only matters to the extent it impacts patient care.
Does your income attract others to train in your specialty? Do your fees reward you for taking extra call each month?
We want the world to think we would do extra call for free. But it is not true. If people are not paid properly, call schedules become impossible to fill. Emergency departments become short staffed.
I need solid fees in place to guarantee that a vascular surgeon has moved to our area and is eager to answer my call at 3 in the morning. If I have no vascular surgeon, my patient dies.
The PPSA is not about you as a doctor. It’s about whether it is good for patient care.
Does the PPSA build healthcare?
Will your PPSA vote increase care overall or will it undermine the frail shell we have currently?
I cannot in good conscience support this contract. In this PPSA vote, I will vote no.
